Dyadic Care in Action: Technical Assistance to Expand Parent/Child Social-Emotional Care

By Kathryn Margolis

Associate Clinical Professor, UCSF Departments of Psychiatry and Pediatrics

Director, ZSFG Division of Integrated Behavioral Health

Associate Director, ZSFG Primary Care Behavioral Health, Pediatrics

Family health care providers often struggle with knowing their patients have social-emotional and societal challenges that deeply affect their health, but which there isn’t time to unpack in a standard medical visit. To address this at the pediatric clinics I lead in San Francisco, we use HealthySteps, an evidence-based, dyadic care model that installs specialists in the pediatric office to provide broader support to children and families when they come in for infant well-child visits. Recently, our clinics conducted a survey of health care providers to gauge the impact of HealthySteps on children’s care.

The providers reported that having HealthySteps Specialists in their practices allows them to focus on a child’s medical care, while not ignoring or side-stepping broader issues that affect their health. One provider reported: “The support from HealthySteps has dramatically improved the care I provide to my patients and their families. Before their involvement in the clinic, I often felt overwhelmed by the needs of my patients and stressed by the limited time I had to try and address them. Now, with HealthySteps I know that I don't have to try and address everything alone. I know I can provide a warm handoff and start my next appointment with the knowledge that my patient will be in good hands.”

In pediatric clinics with HealthySteps, all children receive child developmental, social-emotional and behavioral screenings; screening for family needs; and education and anticipatory guidance. A smaller group of children receive short-term supports, including developmental and behavior consults. Some children are recommended for comprehensive services, including team-based well-child visits, care coordination, and systems navigation. For these second two groups of children, child development specialists work with the families to address developmental and behavioral health concerns as soon as they are identified, bypassing the many obstacles families face when referred to offsite behavioral health services. In cases where outside referrals are made, the specialists follow up with families to make sure they receive the services.

Dyadic care models like HealthySteps provide important support to families with young children. Researched and implemented for decades, dyadic care has been shown to improve outcomes for parents and children. Such care is particularly important in this pandemic- recovery time, which exacerbated mental health concerns, family stress, isolation, and income insecurity, particularly for BIPOC families who already face health inequity due to structural racism and oppression.

I am passionate about ensuring that families receive these services. To do health promotion and prevention, it requires everyone in the clinic to change the way they practice. There needs to be leadership engagement, changing of operational workflows, and integration of the Behavioral Health clinicians into the medical team. All staff need to be able to understand the importance of early intervention so that they can do their part on the care team to identify a behavioral health risk in infancy, and ensure we respond by providing access to critical services when a risk is identified. And families need to hear and learn that the screenings are worth their time and that they are not being singled out in a negative way; rather, families are our partners in learning how to best promote their child’s health by way of their family’s health.

All of this takes a lot of hard work, but it’s transformative. It requires meticulous and consistent focus on clinic operations, data infrastructure building, continuous quality improvement and feedback loops, and education/training at all levels. Every clinic is unique and different and needs to tailor its program, but there are similar themes with the challenges and how to be successful, which is why this type of rollout lends well to a cohort-based, collaborative learning model.

That’s why we are launching an Innovative Pediatric Technical Assistance Initiative at UCSF to help pediatric practices build evidence-based models into their standards of care. The TA Initiative will ensure that pediatric practices across the state are equipped with the technical expertise to provide early childhood behavioral health and developmental care -- and receive payer reimbursement for these services.

That last point is important. We cannot rely on pediatric practices to do this critically impactful work without reimbursement. We were thrilled to see that Governor Newsom’s May revised budget proposal this year includes funding to create a specific dyadic care Medi-Cal benefit. If passed by the legislature and signed by the Governor, this new benefit will mean that providers will be able to receive reimbursement for the full range of dyadic care services, which was not possible before. It is a groundbreaking policy, signaling this Administration’s intent to support the emotional wellbeing of children and families, and makes strides towards the Surgeon General’s goal of reducing Adverse Childhood Experiences by half.

As of now, the Innovative Pediatric Technical Assistance Initiative has begun work with clinics in San Francisco and Santa Clara. We look forward to expanding and providing TA services to many other parts of the state, to ensure that clinics and pediatric offices can offer these vital services to children and families across California.

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